- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.80 / $7,144.91 / $7,144.91
| Professional | | $1,558.80 | $7,144.91 | $7,144.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,178.39 / $2,178.39 / $2,178.39
| Facility | | $2,178.39 | $2,178.39 | $2,178.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,578.64 / $2,178.39 / $2,178.39
| Professional | | $1,578.64 | $2,178.39 | $2,178.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,178.39 / $2,671.05 / $2,701.40
| Facility | | $2,178.39 | $2,671.05 | $2,701.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.20 / $1,885.90 / $2,880.50
| Professional | | $1,331.20 | $1,885.90 | $2,880.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,104.44 / $2,428.21 / $3,811.91
| Professional | | $2,104.44 | $2,428.21 | $3,811.91 |